Department of Psychiatry, University of Pittsburgh School of Medicine.
J Clin Psychiatry. 2014 Feb;75(2):e100-7. doi: 10.4088/JCP.13m08442.
Late-life depression frequently co-occurs with cognitive impairment. To inform clinical management of these conditions, we examined the hypotheses that, relative to cognitively normal elders meeting DSM-IV criteria for major depressive disorder, those with cognitive impairment would require greater intensity of pharmacotherapy to reach criteria for antidepressant response and would take longer to respond.
Using data from the MTLD-3 study, we conducted a series of secondary analyses examining the implications of cognitive impairment for short-term, open-trial pharmacotherapy of late-life depression (major depressive disorder in individuals 65 years and older). The treatment algorithm consisted of 3 steps: initial treatment with a selective serotonin reuptake inhibitor (SSRI), a switch to a serotonin-norepinephrine reuptake inhibitor (SNRI) if the patient did not respond, and addition of an atypical antipsychotic if the patient did not respond to the SNRI. The first subject entered the protocol in April 2004, and the last subject exited in September 2009. We examined data for participants who completed the acute phase of MTLD-3 as responders and received a cognitive diagnosis (N = 153) based on National Alzheimer's Coordinating Center (NACC) Uniform Data Set criteria. We divided participants into 3 groups on the basis of NACC cognitive diagnosis: no cognitive disorder (n = 74), mild cognitive impairment (n = 60), and dementia (n = 19). For each group, we calculated the proportion of participants requiring first- (SSRI), second- (SNRI), or third-step (add-on atypical antipsychotic) treatment to meet criteria for response (17-Item Hamilton Depression Rating Scale score ≤ 10 for 3 consecutive weeks). We compared time to response across groups and correlates of nonresponse.
The 3 groups did not differ in intensity of pharmacotherapy (P = .68) or time to response (P = .84). Nonresponse was more strongly correlated with longer major depressive episode duration (P = .0015), presence of recurrent depression (P = .002), and younger current age (P = .047), rather than cognitive status (P = .61).
Cognitive status does not appear to impact short-term pharmacotherapy response variability in individuals whose depression responds to treatment with open-trial antidepressants delivered in a supportive, university-based medication clinic.
老年期抑郁症常与认知障碍共病。为了为这些病症的临床治疗提供信息，我们检验了以下假说，即与符合 DSM-IV 重性抑郁障碍标准且认知正常的老年人相比，有认知障碍的老年人达到抗抑郁药应答标准所需的药物治疗强度更大，以及他们的应答时间更长。
我们利用 MTLD-3 研究的数据进行了一系列二次分析，以检验认知障碍对老年期抑郁症短期开放试验药物治疗（65 岁及以上个体的重性抑郁障碍）的影响。治疗方案包括 3 个步骤：初始治疗使用选择性 5-羟色胺再摄取抑制剂（SSRI），如果患者没有应答，则转换为 5-羟色胺-去甲肾上腺素再摄取抑制剂（SNRI），如果患者对 SNRI 没有应答，则添加非典型抗精神病药。第一位受试者于 2004 年 4 月进入方案，最后一位受试者于 2009 年 9 月退出。我们检查了完成 MTLD-3 急性阶段且根据国家阿尔茨海默病协调中心（NACC）统一数据集中的标准接受认知诊断的应答者（N=153）的数据。我们根据 NACC 认知诊断将参与者分为 3 组：无认知障碍（n=74）、轻度认知障碍（n=60）和痴呆（n=19）。对于每组，我们计算了需要第一（SSRI）、第二（SNRI）或第三步（添加非典型抗精神病药）治疗以达到应答标准（连续 3 周 17 项汉密尔顿抑郁量表评分≤10）的参与者比例。我们比较了各组之间的应答时间和无应答的相关因素。
3 组之间的药物治疗强度（P=0.68）或应答时间（P=0.84）没有差异。无应答与更长的重性抑郁发作持续时间（P=0.0015）、复发性抑郁（P=0.002）和更年轻的当前年龄（P=0.047）相关性更强，而与认知状态（P=0.61）相关性较弱。
在接受支持性、以大学为基础的药物诊所提供的开放性抗抑郁药物治疗后，抑郁症状得到缓解的个体中，认知状态似乎不会影响短期药物治疗应答的变异性。
